Radial Artery Angiography and Intervention: Complications

1. Radial Artery Angiography and
Intervention:
Complications
Varinder P Singh, MD
Director, Coronary Intervention and Cath Lab Operations
Columbia University
NY,NY

2. Disclosure Statement of Financial Interest
• I, V. Singh DO NOT have a financial
interest/arrangement or affiliation with one or
more organizations that could be perceived
as a real or apparent conflict of interest in
the context of the subject of this
presentation

3. Complications
• Relatively common
 Radial artery spasm/occlusion
 Vasovagal reaction
 Radial artery dissection
 Ensconced catheter
• Very uncommon
 Perforation/forearm hematoma/ Axillary Hematoma
 Hand ischemia (where there is co-existent ulnar artery flow compromise)
 Granuloma formation at access site (has been associated with hydrophilic
sheath use)
 AV Fistula
 Compartment Syndrome
transradial-summit.org

4. Radial Artery Occlusion
vs Hemostasis Technique
Pancholy S. Catheter Cardiovasc Interv 2008; 72: 335-340
transradial-summit.org

5. Radial Occlusion vs Sheath Size
Spaulding, et al. Cathet Cardiovasc Diag 1996; 39: 365-370
transradial-summit.org

6. Radial Artery Occlusion vs Heparin
Spaulding, et al. Cathet Cardiovasc Diag 1996;39:365-370
transradial-summit.org

7. Radial Artery Occlusion vs
Time to Sheath removal
N=234. Saito, et al. Catheter and Cardiovasc Interv 1999;46: 37-41
transradial-summit.org

8. Reducing Radial Artery Occlusion
Summary
• Patent Hemostasis
• Avoid Spasm
• Smallest Sheath Size Necessary
• Heparin- ? timing of admistration
• Remove Sheath As Soon As Possible
• Can reduce rate to 1% from 5-8%
transradial-summit.org

9. Perforation
transradial-summit.org

10. Perforation

11. Perforation
• Tejas Patel, et al reported 15 perforations out of 34,000
Transradial procedures (0.04%)
• The Key is to recognize the perforation early, as
unrecognized perforations can lead to compartment
syndrome.
• Angiography was performed pre procedure, post procedure,
and anytime a complication was suspected.
• Of these 15, all completed their procedures successfully.
• The perforation was sealed by tamponade with the sheath or
a catheter
Patel, et al J Invasive Cardiol 2009; 21: 544-547
transradial-summit.org

12. Perforation
• If you have encountered a perforation or
are concerned, wrap the arm with ace
bandage, elastoplast, etc.
• Monitor hand for perfusion/ischemia:
color, oximetry, pain/parathesias,
capillary refill, pulse, venous congestion
• Vascular surgery consultation earlier
rather than later
transradial-summit.org

13. Hematoma or Swelling ?
your best friends
External Compression Intravascular Tamponade
LONG Hydrophilic sheath
NOT the Destination Sheath
transradial-summit.org

14. Compartment Syndrome
Compartment syndrome is the most dangerous transradial complication
• A large hematoma causes hand ischemia due to pressure-
induced occlusion of both the radial and ulnar arteries
• Know the signs and symptoms
 Acute pain and tumefaction
 Disturbances in sensitivity
 Pallor of the distal limb, with preserved radial and ulnar pulses.
 Pain on movement of the fingers
 Decreased sensation (touch)
 Pallor and lack of capillary refill
• Emergency surgical consult
 Fasciotomy with hematoma evacuation must be performed as an
emergency procedure
transradial-summit.org

15. Complications
• Ensconced catheter
 Hydrophilic sheath avoids this
• Destination sheath is semi hydrophilic
 Treatment
• Sedation and time
• Anesthesia for general sedation
• Supraclavicluar block

16. Pseudoaneurysm
•Complication of
Compression
•Higher with certain
closure bands
•Thrombin Injection or
compression
Afshar & Nasiri, J Teh Univ Heart Center 3 (2009) 193-196
transradial-summit.org

17. Sterile Abscess
• Granuloma associated
with Hydrophilic sheaths
• Vascular surgery consult
• Conservative management vs
surgical removal
Ian Gilchrist MD, Transradialworld.org
transradial-summit.org

18. A-V Fistula
• Rare complication
• Self Limited Clinical
course
Sanmartin et al, Rev Esp Cardiol. 2004; 57: 581-4
transradial-summit.org

19. Complications
These other complications occur very infrequently
• Infraclavicular hematoma
 Results from perforation of a small
branch of the axillary artery
• Scarring
 Depigmented scar at puncture site due
to undue compression
transradial-summit.org

20. Anatomic Limitations
Anatomic variations
• Retroesophageal origin of
subclavian artery
 0.45 %
 60 % success rate

21. Retroesphageal Insertion

22. Strategies to Manage Potential Procedural
Complications During the Transradial Approach
Complication Management Strategy
Local access Compression of RA both proximally and distally to the puncture site using
bleeding manual pressure (or compression devices)
Perform an RA arteriogram when any resistance to guidewire or catheter
Forearm
insertion occurs
hematoma
ACE™ bandage to forearm
Ensure that occlusion of both the RA and UA does not occur during the
Compartment
procedure
syndrome
Fasciotomy with hematoma evacuation
The puncture site should not be too distal
Access failure If radial loop is present, transverse with hydrophilic guidewires
If RAs are smaller than 2 mm in diameter, use 5F guidewire
Pseudoaneury
Thrombin injection and or mechanical compression
sm formation
Radial artery
Caused by intense spasm, prevent RA spasm
avulsion
Radial Cross perforation site using guidewire with extreme caution and seal the
perforation perforation with the guiding catheter
transradial-summit.org

23. Summary
• Radial complications do occur although
rare
• Early recognition is key
• Low threshold for angiography
• Allmost all can be managed in the lab